Letter of Agency - Change of Provider Form

LETTER OF AGENCY - CHANGE OF PROVIDER FORM AUTHORIZATION TO ALLOW CHANGES TO YOUR TELEPHONE SERVICE PROVIDER (S)

Customer Name: Billing Telephone No(s): Billing Address:

By initialing and signing below, I authorize the indicated change(s) in my telephone service provider(s).

I understand that I can only pre-subscribe to one local dial tone service provider, one local toll provider and one long distance provider for each working telephone number that is billed to me. If I later wish to return to my current service provider, I may be required to pay a reconnection charge to that company. I also understand that my new service provider may have different rates and charges than my current service provider, and that by signing below I indicate that I understand those differences (if any).

1. ______By initialing here and signing below, I authorize to become my new telephone service provider in place of my current provider, for long distance service. I authorize Southwestern Bell Telephone Company to act as my agent to make this change happen, and direct to work with the new provider to make the change. I understand that I may be required to pay a one-time charge per line to switch providers.

2. ______By initialing here and signing below, I authorize Southwestern Bell Telephone Company to become my new telephone service provider in place of my current provider, for local toll service. I authorize Southwestern Bell Telephone Company to act as my agent to make this change happen, and direct to work with the new provider to make the change. I understand that I may be required to pay a one- time per line to switch providers.

3. ______By initialing here and signing below, I authorize Southwestern Bell Telephone Company to become my new telephone service provider in place of my current provider, for local telephone service. I authorize Southwestern Bell Telephone Company to act as my agent to make this change happen, and direct to work with the new provider to make the change. I intend to extend this authority to all of my telephone service, whether the numbers assigned to those services are listed on this document or not. I understand that I may be required to pay a one-time charge per line to switch providers.

Attempt to separately list each telephone number that is to be changed. If more space is needed, please attach a separate list, each page to be initialed by the person signing below. However, by signing this authorization I authorize the above initialed changes to be made to the listed billing number(s), and any additional telephone numbers associated with the listed billing number(s) regardless of whether the numbers are listed in this authorization.

I certify that I have read and understand the above Letter of Agency. After receipt of pricing and installation information from Southwestern Bell Telephone Company, I may decide to terminate this authorization. I further certify that I am at least eighteen years of age, and that I am authorized to change companies for services to the telephone numbers listed above.

Authorized Signature: ______Date: ______Authorized Name (PRINT): Title (PRINT): ______Company Name (For businesses only): Telephone number of individual authorized to make this change(s)

Mail to: Southwestern Bell Telephone Company

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